Optimized Chronic Care for Smokers: Developing and Implementing Integrated Clinical and Systems Interventions in Primary Care

总体摘要 吸烟是导致癌症死亡的首要可预防原因。然而，医疗保健系统并没有 认识到了它们降低吸烟率的潜力；提供和使用吸烟的患者太少了 吸烟治疗和这样的治疗效果不够好。本计划项目解决了这些关键问题 通过开发一种特别有效的综合慢性护理吸烟治疗来减少障碍 通过4个个人项目和3个核心，了解医疗保健中的吸烟流行率。此计划项目将平衡 通过多阶段优化等强有力的创新研究方法实现内部和外部效度 战略(MOST)，同时使用现实世界的初级保健诊所、患者和工作人员，并使用RE-AIM 加强其对公共卫生的影响的框架。使用析因设计，戒烟筛查项目将 在608名愿意戒烟的吸烟者中评估四个实验因素，以首次确定哪一个 干预策略(准备用药、延长用药和咨询方式)结合在一起 生产特别有效的优化Varenicline和联合尼古丁替代疗法(C-NRT) 基于费用和一年禁欲的治疗方案。卫生系统REACH干预项目 我将首次使用析因实验来评估三种旨在增加使用 在1664名最初不愿戒烟的吸烟者中，戒烟治疗(即REACH)超过2年：1)金钱激励 使用吸烟治疗，2)基于电子健康记录(EHR)的自动化定制外展，3) 护理管理。将开发优化的REACH干预方案，以产生特别高的 最初不愿戒烟的吸烟者使用varenicline和C-NRT戒烟治疗的比率。经过优化的 CARE项目将包括两个随机对照试验(RCT)，评估优化的戒烟 以及在STOP和REACH项目中开发的REACH干预方案。一个RCT将进行比较 优化戒烟治疗与标准护理(医生和戒烟转介)在1年内戒烟 600名吸烟者愿意戒烟。第二项RCT将比较组合优化的伸展和停止 900名吸烟者最初的戒烟治疗使用和1年戒烟的干预与标准护理 不愿放弃。实施项目将评估覆盖范围、实施情况(保真度、适应性、 与有效性的关系)、患者代表性和其他3项干预措施的维持 在患者、员工、诊所和系统级别使用电子病历、调查、定性和观察数据的项目。这 计划项目将由管理和物流、数据分析和优化核心以及 共享资源：通过增强的EHR协作医疗系统和招聘。本计划 该项目将为医疗保健开发一种慢性护理吸烟疗法，包括优化覆盖范围和 戒烟干预措施，易于实施和传播，并显著增加使用 戒烟治疗的有效性和有效性，最终降低吸烟率和癌症死亡率。

Overall Summary Tobacco smoking is the leading preventable cause of cancer death. However, healthcare systems have not realized their potential to reduce smoking prevalence; far too few patients who smoke are offered and use smoking treatments and such treatments are insufficiently effective. This Program Project addresses these key obstacles by developing an especially effective comprehensive chronic care smoking treatment to reduce smoking prevalence in healthcare via 4 individual projects and 3 cores. This Program Project will balance internal and external validity via powerful, innovative research methods such as the Multiphase Optimization Strategy (MOST) while also using real-world primary care clinics, patients, and staff, and using the RE-AIM framework to enhance its public health impact. Using a factorial design, the Cessation Screening Project will evaluate four experimental factors in 608 smokers willing to quit to determine, for the first time, which intervention strategies (Preparation Medication, Extended Medication, and Counseling Modality) combine to produce especially effective Optimized Varenicline and Combination Nicotine Replacement Therapy (C-NRT) Treatment Packages based on cost and 1-year abstinence. The Health System Reach Interventions Project will, for the first time, use a factorial experiment to evaluate three interventions intended to increase the use of cessation treatments (i.e., reach) over 2 years in 1664 smokers initially unwilling to quit: 1) Monetary Incentives to Use Smoking Treatment, 2) Electronic Health Record (EHR) Based Automated Tailored Outreach, and 3) Care Management. An Optimized Reach Intervention Package will be developed that produces especially high rates of varenicline and C-NRT cessation treatment use by smokers initially unwilling to quit. The Optimized Care Project will comprise two randomized controlled trials (RCTs) that evaluate the Optimized Cessation and Reach Intervention Packages developed in the Cessation and Reach Projects. One RCT will compare Optimized Cessation Treatment versus Standard Care (physician & quitline referral) on 1-year abstinence in 600 smokers willing to quit. The second RCT will compare combined Optimized Reach and Cessation Interventions versus Standard Care on cessation treatment use and 1-year abstinence in 900 smokers initially unwilling to quit. The Implementation Project will assess the reach, implementation (fidelity, adaptation, relation with effectiveness), patient representativeness, and maintenance of interventions in the other 3 projects using EHR, survey, qualitative, and observational data at patient, staff, clinic, and system levels. This Program Project will be supported by Administration & Logistics, Data Analysis, and Optimization Cores and by shared resources: collaborating healthcare systems and recruitment via an enhanced EHR. This Program Project will develop a chronic care smoking treatment for healthcare that includes optimized reach and cessation interventions that can be readily implemented and disseminated and that markedly increase the use and effectiveness of cessation treatment, ultimately reducing smoking prevalence and cancer deaths.